Laserfiche WebLink
0921004023.4 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State LE C1WM 181(NeCaliforw0 Survey Form - Page 1 I1 - 1088415 <br /> LE <br /> CIwMB 181(New nage y g <br /> California Integrated Waste Management Board J `� <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: l l IL' 6 lQ Q 1,5L3] tRoutine Re-inspection Q Referral Observation <br /> Local c_�'^ L If Referral,choose referral type(Fill one) <br /> Identifier: l ` St�C� 1V1 �C(XV r 0 CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0 61 <br /> Physical Address 4 <br /> L_-3 6 P6(l:;,r-mc� <br /> Streetl� (/�� Inspection Date <br /> Citys"I vC ` O�J Time In Time Out <br /> Srate ZIP Ccde _ <br /> Business Rep Title /� 1 I ; IAM ®AM <br /> �AII�IT 1"��� L-� �� ' �SJQPM I l i� ( ' 131 OI QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) <br /> .(Fill one only) (Fill all that apply) (Fill all that apply)' (Fill all that apply) <br /> ! . f O. Ob Active .O Passenger ® Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> __ O O Inactive 4&Truck / <br /> Longitude - I O PlannedQ OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair I& Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station O Hauler 0 Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFESTREQUIREMENTS Notice Of violation Q E•xten ion <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance headline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements at <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/C-IWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In G�ompliance - No Violations <br /> O 1 O Other: § <br /> Comments _ .•_e_ —t l_ )1L e-yjinrj <br /> 0 [1[,111 t f 1 <br /> CJ ---,) f tL Or 5_0�C_o n Ge rr! <br /> Inspection Form Included: �o�N <br /> Comments Included: Q 1 �— <br /> Bus• s e ' gnature umber Insp ctcks nature Phone Number <br /> INSTRUCTIONS ON B CK or ect. neorrect: E X A M P L E 1 :2 3 62081 <br /> White Cop CIW Yellow Copy.Operator Pink Copy.LEA <br />